** Siskiyou Century ~ Ride Date: 9-11-2004 **
>> Registration Form in PDF format ~ Download Adobe PDF Instructions

Print & Mail Registration Form --
TO REGISTER: Please print this form, complete all information, then Mail in a completed copy of this registration and waiver form
along with your check.
One Form Per Applicant! Photocopy this form for any additional riders.

Name:_____________________________________________________ Sex: M___ F___ Age:______
Mailing Address:______________________________________________________________________
City:__________________________________________ State:_________ Zip:____________________
Phone: ( )___________________________

E-mail Address:______________________________
Emergency Contact:________________________________________ Phone: ( )________________

We MUST have an emergency contact name and phone number (of someone not attending the ride)!

Registration - Ride Fees: Quantity Price Amount
34 Miles - Metric 1/2 Century:


$20.00 = $_________
64 Miles - Metric Century: One $25.00 = $_________
100 Miles - The Century: One $30.00 = $_________
Late Fee: (after 8/30/04) One $5.00 = $_________
Extra Meal Ticket(s): ________ x $8.00 = $_________
Tour T-shirts: S_____ M_____ L_____ XL______ XXL______ x $12.00 = $_________
Tour T-shirts
(after 8-30-04) :
S_____ M_____ L_____ XL______ XXL______ x $15.00 = $_________
RV Space at Fair Grounds Friday night only $12.00 = $_________
Camping Friday night only $9.00 = $_________



NOTE: T-Shirts are not included in the Ride Fee. All rides include a lunch served from 11:30 am to 5:30 pm. Helmets are mandatory for ALL riders. Make checks payable to "The Siskiyou Century" and mail this form to: The Siskiyou Century c/o Yreka Chamber of Commerce, 117 West Miner St., Yreka, CA 96097. If you have any questions E-mail: contact@siskiyoucentury.com or call us at 530-842-1649.

Accident Waiver And Release Of Liability
In consideration of my acceptance for entry in the SISKIYOU CENTURY for 2004 I hereby waive, release and discharge any and all claims for damages for death, personal injury, or property damage which I may have or which hereafter may accrue to me, as a result of my participation in said event. This release is intended to discharge in advance the promoters, sponsors, and any involved municipalities or other public entities and their respective agents and employees, from and against any and all liabilities arising out of or connected in any way with my participation in said event, even though that liability may arise out of negligence or carelessness on the part of the persons or entities mentioned above.
I further understand that this event will require me to engage in strenuous physical activity at high altitude and in possible adverse weather conditions. I further understand that serious accidents occasionally occur during bicycle riding; and the participants in bicycle riding occasionally sustain mortal or serious physical injury, and/or property damage, as a consequence thereof. Knowing the risk of bicycle riding, nevertheless, I hereby agree to assume these risks and to release and hold harmless all persons or entities mentioned above who (through negligence or carelessness), might otherwise be liable to me (or my heirs or assigns) for damages. It is further understood and agreed that this waiver, release and assumption of risk, is to be binding on my heirs and assigns.
I further agree to abide by all the rules and regulations set forth in this event. I acknowledge that an approved helmet is required to be worn by me at all times while riding during these events. Section 1542 of the civil code of the state of California which provides: "a general release does not extend to claims which the creditors does not know or suspect to exist in his fervor at the time of executing the release, which if know to him must have materially affected his settlement with the debtor:, and all laws of all other states of like, or similar affect, and the benefits thereof, are hereby waived.

All riders being registered must sign this release!

NAME___________________ AGE_______ SIGNATURE________________________ DATE: ____________
NAME___________________ AGE_______ SIGNATURE________________________ DATE: ____________
S ignature of parent or guardian is required if applicant is under 18 years --
No one under 13 may ride unless accompanied by an adult!

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